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HomeMy WebLinkAbout18536 (11)CITY OF DIAMOND BAR DEPARTMENT OF CO MUNFFY & DEVELOPMENT SERVICES a 21825 E. Copley Drive /' (909) 860-3195 Fax (909) 861-3117(�; PRESS BUILDING PERMIT APPLICATION k FIRMLY JOBSITE ADDRESS*y L APN LOT-. T T OWNER " ADDRESS i CITY ZIP TE ` APPLICANT TEL. CONTRACTO t� ADDRE CITY ZIPLrT ARCH/ENG/ n / A DESIGNER/ !"C� ADDRESS CITY ZIP ___ TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY C TY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC. TURE, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FLE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U - CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONSCODE)ORTHATHEOR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TON, ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJEC I5 THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SS00) )'. - ❑ I, ASOWNER OF THE PROPERTY, OR MY FMPLCYEES WITH WAGES AS T HEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044 RUT NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NO, APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELFOR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENT 15 SOLD WITHIN ONE YEAR OF COMPLE- TION, THE OWNER -BUILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). -11. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS. AND PROFESSIONS CODE. THE CONTRACTORS U CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUII. DS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) I ICFNSED PURSUANT TO THE CONTRAC. TORS LICENSE LAW ). f -I I AM EXEMPT UNDER SFC, _ B. 8 P.C. FOR THIS REASON DATE _„^ OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE 15 IN FU ORCE AN EFFECT. S ~f LICENSE —'� _ LIC NO � 1 li_ _ DATE ' CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF INSURE FOR WORKERS' PENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR COOP, FOR THE PERFORMANCE THE WORN FOR WHICH THIS PERMIT IS ISSUED 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH IRIS PERMIT IS 155uED. MY WORKER' P N EC ER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER .— THE SECTION NEED NUT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($1W) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER BOAS TO BECOME SLEUECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERSCOMPENSATION PROVISIONS OF SECTION 37DO OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: _ APPLICANT: I WARNING: FAILURE 70 SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 1'0 ONE HUNDRED THOUSAND DOLLARS (5100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I SECTION 3708 OF THE LABOR I:OUE, INTEREST, AND ATTORNEY'S FEES. 1 CONSTRUCTION LENDING AGENCY HEREON AFFIRM UND ER OF THE Y OF PERJURY THAT THERE 15 CONS7RUCTION (SEC. LENDING AGENf:V OR THE PEHFORMAh CE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.I. 1 LENDER'S NAME LENDER;SADDRESS ICERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING 3 CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY T ENTER LPON THE ABOVE -ME TIONEO PROPERTY FOR T'. NPURPOSES. i ] PEH LEN PINT) J D 51GNAT r O( RMTTTEE DATE APPLICATI PER IT P/C DATE NUMBER�# ISSUE r TYPE OCC DATE _ CONST. GROUP ZONING SETBACK$ FRONT \ RW ❑ REAR ❑ _ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE 1 NO. DWEL. NO. /( UNITS STORIES �_ BEDROOMS (j DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREA(VALUATION SFR/ADD/REM U) Garage/Carport W LLL PatioiDeck W Pocl/Spa Z Re -Root Commercial m Valuation :A QUANTITY DESCRIPTION FEE J Q U H U W J W CD Z_ m D_ J U_ Z Q U W l I CONSTRUCTION J PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE \ ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE:��' PRE -ALT FEE: TOTAL FEES�1 COMMENTS RECP?. NO. PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Uopy, LiULUtNHULH—rne U.Opy, anttrv—Rppucam s wpy UI-1)II--D D,Ifti CITY OF DIAMOND BAR DEPARTMENT OF COI—M—IUNTfY & DEVELOPMENT SERVICES 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION f-4— PRESS FIRMLY JOBSITE — RE SI ADD S APN LOT T T_ OWNER ADDRESS CITY ZIP 7E APPLICANT TEL. CONTRALTO L L' ADDRE CITY ZIP T j—; ""c ARCH/ENG/ -1 DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR COUNTY WHICH REQUIRES A PEFiM1T TO CONSTRUCT, ALTER, IMPROVE. DEMOLISH, CR REPAIR ANV STRUC— TUBE. PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE IAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONSCODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BAST S FOR THE ALLEGED E%EMF- TION. ANV VIOLATION OF SECTION 7031.5 BY ANV APPLICAN T FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS (5500) ): - ^ I, AS OWNER OF THE PROPERTY, OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOH SALE (SEC. 7044, BUT NESS ANO PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NO. APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMP ROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EM PLOVEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVE R, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION, THE OWNER -BUILDER WII1 HAVE THE BURDEN OF PROVING 'HAT HE OR SHE DID NOT BUILD OH IMPROVE FOR THE PURPOSE OF SALE). ^ 1, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO dUII.DS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PFI03EC-FS WITH A CONTRACTOR(SI LICENSED PURSUANT TO THE CONTRAC— TORS LICENSE LAW). f I I AM EXEMPT UNDER SEC. _ B. S P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 30F THE BUSINESS AND PF.OFESSiONS CODE. AND MV LICENSE IS IN FU ORC^4N EFFECT. J ( �j _ LIC. NC>. LICENSE li CONTRACTORS. DATE'— WORI'(ERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJVRV ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' CgIPPENSATION, AS PFOVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE /q— THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION r 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKER' P 9Cy1N rE-C IER AND POLICY NUMBER ARE: CARRIER 4 V U POLICY NUMBER - (THIS SECTION NEm NOT BE CLY.APLETED OF THE PERMfT IS FOR ONE HUNDRED DOLLARS (81001 OR LESS). 1 I I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE j WORKERS' COMPENSPTION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LA80R CODE. I SHALL FORTH\NITH COMPLY WITH THOSE PROVISIONS. r DATE _ APPLICANT: 1 WARNING: FAILURE TO SECUR'.E WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE 1 SUBJECT AN EMPLOYER TO CFIIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (f 100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN 1 SECTION 37080E THE LABOR I:ODE. INTEREST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY - FOR THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.). J LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE TO COMPLY WITH ALL GIN AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY T ENTER UPON THE CONSTRUCTION 3 ABOVE -ME TIONED PROPERTY FOR TI N PURPOSES. 3- 7 D PER EEN RINT) C (o./ UST L" DATE 0 SIGNATURE 0" RMITTEE C" WHITE-Department Copy, YELLOW-Finance Copy, PINK-Assessor copy, LiuLUtrvrtuu-rile L,opy, oneery-.